Health inspection·January 11, 2024

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accommodate the residents needs for tissue paper for Resident 37, one of one sampled resident, (a disposable piece of absorbent paper used as a handkerchief), who did not speak English, when tissue paper was unavailable to the resident for two days. Residents Affected - Few This failure did not create an infection-controlled, individualized, respectful, and home-like environment. Findings: Resident 37 was admitted to the facility on [DATE] with diagnoses including hemiplegia, left side, (one-sided muscle paralysis), bed confinement, stroke (loss of blood flow to brain, damaging brain tissue), diabetes, (disease of too much sugar in blood), Depressive disorder, and high blood pressure. During an interview on 12/13/23 at 11 AM, Resident 37 had been asking for facial tissues for two days and staff said there were no tissues available (over the weekend). During an interview on 12/14/23 at 2:30 PM, the Supply Supervisor stated he was available to retrieve supplies if he had been notified. Review of Facility Central Supply Program, dated December, 2016, Policy and Procedure indicated, The supply department establishes approved suppliers and facility volume .for all departments .1. The individual at the facility who needs a supply .finds the item required on the Approved Supplier List (ASL) which is found in the Central Supply (CS). 2. The ASL will indicate the approved suppliers for such supply .that will contain all necessary product .3. The ordering instructions found in point 2 should be followed but only after obtaining the approval of the facility administrator .5. If the product is not included in the CS Manual, it should be ordered locally .6. The ordering party will receive the invoices for the ordering party to immediately process such invoices . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056122 If continuation sheet Page 2 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056122 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Millbrae Care Center 33 Mateo Avenue Millbrae, CA 94030 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure the allegation of accidents, was promptly reported to the State Agency (SA, which is the California Department of Public Health, CDPH) in accordance with facility's policy and procedure for one of two sampled residents (Resident A). This failure to report fall with injury has potential for further accidents to happen not being reported. Findings: During a review on 1/11/24 at 11AM, of facility document, admission Record, dated 12/20/23, indicated, admitted on [DATE] with diagnoses including: Lymphoma (cancer of the lymphatic system), Unspecified Cord Compression( Pressure in the spinal cord), Diabetes Mellitus( high sugar levels), Anemia (low blood count). Review of facility document, Nursing admission Assessment, dated 12/20/23 indicated, for mobility, full ROM (range of motion) all extremities, moderate ability to roll from side to side. Summary: indicates, resident able to perform transfers. Review of facility document, progress notes admission Summary, dated 12/20/23, indicated, admitted from acute with diagnosis of Small Bowel Obstruction, for PT/OT/ST. Alert and oriented x 4, denies pain, able to move upper and lower extremities without limitations . On 12/21/23, S/P new admit day 1, A/O x 4, no pain/discomfort, uses urinal, one person limit assist with ADLs,(Activities of Daily Living). On 12/21/23, Resident alert and verbally responsive. No c/o of pain or discomfort noted. Continue therapy care. S/P new admit. Resident moved to another room. On 12/22/23, around 10:15 AM heard a big thud, resident laying on the floor on his back, head touches the window glass close to the restroom. Assessment done by this writer and one LN (licensed nurse) from head to toe, noted small bump on the back of his head, no bleeding noted, no dizziness, no headache, no vomiting noted, denies any pain, able to move all extremities, with friend on the side translating, per resident he is okay. Transferred back to bed with two persons assist. NVS checked BP 125/75, T-97.6, P-98, RR-18, O2 Sat- 95% RA, AOx4. After 20 minutes of reassessment noted complaining of mild headache, pain on his back of the head 5/10. Called 911 10:35 AM, paramedics came at 10:40 AM, handed pertinent papers and took over. Resident/911 left the building 10:58 AM, alert and responsive. Resident responsible to self. Daughter came to the building 11:40AM, letting her know that her dad was sent out to acute for Evaluation r/t S/P Falls, Review of Care plan, dated 12/21/23, indicated Patient with acute decline in functional mobility, decreased balance and coordination of movement and decreased safety awareness. PT (Physical Therapist clarified orders as intervention Review of Order Summary Report, dated 12/22/23, indicates, Resident has the Capacity to make Health Care Decisions- NO. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056122 If continuation sheet Page 3 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056122 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Millbrae Care Center 33 Mateo Avenue Millbrae, CA 94030 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Interview om 1/11/24 at 11:45 AM, with RN1, stated, If patient has a fall, License nurse assess patient and sure no injury. Neuro check done. If needs to be send out, MD will agree. Risk Management is completed after a fall/or COC (change of condition) for analysis. Monitor for 72 hours progress notes and neuro check x 72 hours S/P Fall. Care plan update, IDT meeting. Not all falls are reportable but if there is injury, has to be reported. Residents Affected - Few During an interview on 1/10/24 at 2:28 PM , with family, stated, he fell in the bathroom, had surgery of the head and is now in another rehab center for recovery, cannot swallow. Review of hospital Discharge Summary, dated, 1/11/24, indicated, admission date:12/22/23, discharge date : 1/2/24 .Traumatic brain injury .12/22: R Craniotomy for evac of SDH. Review of facility document, Abuse and Neglect Prohibition Policy, dated 6/22, indicates. Reporting of Incident, investigations and facility's response to the investigation: 1. All alleged violations- immediately but not later than: 1. 2 hours - if the alleged violation involves abuse or results in serious bodily injury. Iv. The licensing and Certification District Office is required to receive these reports. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056122 If continuation sheet Page 4 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056122 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Millbrae Care Center 33 Mateo Avenue Millbrae, CA 94030 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0637 Assess the resident when there is a significant change in condition Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to identify and document changes in Resident's A condition when: weight loss started on 1/12/23, IDT (Interdisciplinary Team) meeting done on 8/14/23, The care plan had no updates on intervention since 2019. Residents Affected - Few These failures had the potential for Resident 1's condition not assessed and needs not addressed, could result in Resident A not getting the care that she needs. Findings: During a review of facility document, admission Record, dated, 1/11/24, indicated, admitted on [DATE] with diagnoses including: Cerebral Infarction (stroke), Dysphagia (problem with swallowing), Dementia(loss of memory), Epilepsy (Involuntary jerking movement of the body), Sepsis ( generalized Infection). Patient discharged to acute on 12/30/23. Review of Hospital H&P, dated 11/16/23, indicated, Full code, patient designated conservator as surrogate decision maker. Chief complaint: Hypoxia (lack of oxygen), female with history of Stroke, dementia who is bedbound and aphasic with slurred speech presents with hypoxia, fever, and low blood pressure. ED Course: she was febrile 104 degrees. BP was 54/38 she was tachypneic. Requiring 6 L of oxygen. Labs were abnormal admission was requested: 1. Septic Shock secondary to complicated pyelonephritis (kidney infection), obstructive nephrolithiasis (kidney stone). 2. Acute respiratory failure with hypoxia, 3. Acute kidney injury. Back to facility 11/30/23. Review of Care Plan on nutritional problems, indicated wt loss from 1/12/23 to 11/12/23, revised 11/12/23. Goal : the resident will maintain goal weight of 128 #, revision on 12/5/23. Interventions: date initiated: 3/1/2019, one revision on 8/21/22. All the other interventions initiated 3/1/19, no revision dates, no new care plans interventions added or deleted. Other interventions initiated: 2/24/21, no revision and no new interventions added. Review of Section c- Cognitive Pattern, dated 11/26/23, indicated, BIMS (Brief Interview for Mental Status) a tool to assess mental status, 0- not completed, (resident is rarely/never understood. Review of Nutritional Initial Assessment, dated, 12/1/23, indicated, Resident has been in and out of hospital. PO has been good overall. WT fluctuation. BMI WNL. No other changes. Will monitor need for oral supplements. Gradual wt loss may be acceptable. Continue poc. Review of Weight Variance IDT (Interdisciplinary) Review, dated 8/14/23, indicated, significant loss 6 lbs in 30 days, 16 lbs in 180 days. Interventions: Fortified diet, Pureed texture, nectar consistency. Ensure 237 ml daily. Recommendation; weekly weights x 4. These are not found in care plan. Review of MDS (minimum Data Set) Section K- Swallowing/Nutritional Status, dated 12/7/23, indicated,

K0300. Weight Loss : 0. K0310. Weight gain : 0. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056122 If continuation sheet Page 5 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056122 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Millbrae Care Center 33 Mateo Avenue Millbrae, CA 94030 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0637 Assessment did not address weight variance as stated in IDT review. Level of Harm - Minimal harm or potential for actual harm An interview on 1/11/24 at 1:40PM, with LVN (licensed Vocational Nurse), stated, Patient is alert, non-verbal, don't understand, total care with ADLs and feedings. easy to care for Last year started coming, husband called 911 for urology appointment follow-up. MD cannot take her, no coverage on 12/23/23 . Residents Affected - Few Then she was readmitted back here. Patient had a significant weight loss in November 2023, during her change of condition. when patient has a weight loss, a referral is sent to RD (registered Dietitian) and ST(speech therapist), tests done as recommended by RD to assess cause of weight loss. Then supplements are ordered per MD/RD. Weights taken weekly for a month to monitor weights. Review of the facility document.Weights and Vitals Summary, dated, 2/2/24, indicated, 11/9/23 weight: 128 lbs, -16lbs, 10% change. Entered in care plan problem on 11/12/23, No intervention updates. No Change of Condition record for weight loss.found in chart, LVN confirmed. Review of facility Comprehensive Plan of CAre, dated 12/16, indicated: 12. Re-evaluate and modify care plans as necessary to reflect changes in care, service and treatment, quarterly, and with significant changes in status assessment. 13. Care plan evaluation must occur in response to changes in the resident's physical, emotional, functional, psychosocail or communicative status as they occur, as well as following the RAI guidelines. 14. Ensure that care plan evaluation includes the following: 15. The resident's progress toward goal achievment is evaluated on or before the target date. 16. The status of progress toward goal achievemnt is documented in the care conference notes as part of the resident's medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056122 If continuation sheet Page 6 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056122 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Millbrae Care Center 33 Mateo Avenue Millbrae, CA 94030 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide preventive treatment and services to maintain and improve range of motion (ROM, the extent or limit to which a part of the body can be moved) for 18 of 18 sampled residents (Resident 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18,) when physician order for Restorative Nursing Assistant Program (RNA, nursing interventions that promote the residents ability to adjust to living as independently and safely as possible) was not implemented. The facility failure had the potential for the residents to limit the ROM and a possible development of a contracture (shortening of muscles and joints which limit and interfere with daily functioning). FINDINGS: 1. A review of the face sheet indicated Resident 1 was admitted with diagnoses including rheumatoid arthritis (painful swelling of the joints) and muscle weakness. Minimum Data Set (MDS, a standard assessment tool) dated 10/6/23, indicated Brief Interview of Mental Status (BIMS, a brief memory test to help determine cognitive functioning [mental abilities, includes thinking, learning, and problem solving] score 1-7 severe impairment, score 8-12 moderately impaired, score 13-15 little to no cognitive impairment) score of 15. During an interview on 12/19/23, at 10:18 AM, Resident 1 stated that there was no RNA for months. Resident 1 stated, I am supposed to walk. I can barely walk. Resident 1 further stated she had to ask her doctor to write an order for Physical Therapy (used to help people improved mobility and muscle strengthening). A review of the care plan for Resident 1 dated 2/4/23, indicated, the resident has limited physical mobility related to contracture's of bilateral upper extremities (BUE, both arms) and (both lower extremities (BLE, both legs). During an interview on 12/20/23, at 1:56 PM, Physical Therapist Assistant (PTA) 1 stated, I am currently working with [Resident 1 named]. There was no RNA for over a month. 2. A review of the face sheet indicated Resident 2 was admitted with diagnoses including difficulty in walking, sciatica (condition where pain travels from the lower back down to each leg) and history of left femur (thigh bone) fracture (broken bone). A review of the MDS dated [DATE], indicated BIMS score of 11. During a review of the physician order for Resident 2 dated 9/20/23, indicated, RNA Program for Active Range of Motion (ROM) to (UBE/BLE) to maintain functional strength, maintain ROM and to decrease risk of contracture's and ambulation with front wheel walker (FWW, an assistive device) to maintain functional mobility, every Monday, Wednesday, and Friday. A review of the care plan for Resident 2 revised on 4/29/23, indicated, impaired physical mobility related to history of left hip fracture (broken). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056122 If continuation sheet Page 7 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056122 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Millbrae Care Center 33 Mateo Avenue Millbrae, CA 94030 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm During an interview on 12/21/23, at 7:56 AM, Resident 2 stated, No one help me exercise. I try to walk by myself. A review of the Restorative Nursing Record for Resident 2 indicated RNA program was not implemented on 9/2023, 10/2023 and 12/2023. Residents Affected - Many During an interview on 12/21/23 at 8:04 AM, Licensed Vocational Nurse (LVN 5) stated, There is no RNA. 3. A review of the face sheet indicated Resident 3 was admitted with diagnoses including muscle weakness. A review of MDS dated [DATE] indicated BIMS score of 5. During a review of the physician order for Resident 3 dated 9/24/23, indicated, RNA Program for ambulation with FWW to maintain functional mobility every Monday, Wednesday, Friday. A review of the care plan for Resident 7 revised on 8/22/23, indicated, the resident requires RNA program to maintain functional mobility. A review of the Restorative Nursing Record for Resident 3 indicated RNA program was not implemented on 9/2023, 10/2023 and 12/2023. 4. A review of the face sheet indicated Resident 4 was admitted with diagnoses including epilepsy and repeated falls. A review of MDS dated [DATE], indicated BIMS score of 5. During a review of the physician order for Resident 4 dated 10/12/23, indicated, RNA Program for Active (AROM) on BUE/BLE to maintain functional strength, maintain ROM and to decrease risk of contracture's three every Monday, Wednesday, and Friday. A review of the Restorative Nursing Record for Resident 4 indicated RNA program was not implemented on 10/2023, 11/2023, and 12/2023. 5. A review of the face sheet indicated Resident 5 was admitted with diagnoses including fracture of the right clavicle (collarbone) and right ribs (bony structure on the chest). A review of MDS dated [DATE], indicated BIMS score of 4. During a review of the physician order for Resident 5 dated 10/6/23, indicated RNA Program for AROM on BUE/BLE to maintain functional strength, maintain ROM and to decrease risk of contracture's every Monday, Wednesday, and Friday. A review of the care plan for Resident 5 revised on 10/21/23, indicated, Resident 5 has an Activity of Daily Living (ADL) performance deficit related to limited mobility. A review of the Restorative Nursing Record for Resident 5 indicated the RNA program was not implemented on 10/2023, 11/2023, and 12/2023. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056122 If continuation sheet Page 8 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056122 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Millbrae Care Center 33 Mateo Avenue Millbrae, CA 94030 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 6. A review of the face sheet indicated Resident 6 was admitted with diagnoses including osteoarthritis (pain and swelling of the bones). A review of MDS dated [DATE], indicated BIMS score of 3. During a review of the physician order for Resident 6 dated 10/5/23, indicated, RNA Program to BUE and BLE to maintain functional strength, maintain, ROM and to decrease risk of contracture's every Monday, Wednesday, and Friday. A review of the Restorative Nursing Record for Resident 6 indicated the RNA program was not implemented on 10/2023, 11/2023, and 12/2023. 7. A review of the face sheet indicated Resident 7 was admitted with diagnoses including history of stroke and repeated falls. A review of MDS dated [DATE], indicated BIMS score of 12. During a review of the physician order for Resident 7 dated 7/31/23, indicated, RNA Program for ambulation with to maintain functional mobility every Monday, Wednesday, and Friday. A review of the care plan for Resident 7 revised on 12/4/23, indicated, the resident requires RNA program for ambulation to maintain functional mobility. During an interview on 12/21/23, at 3:20 PM, Infection Preventionist (IP) stated that they were not able to print the Restorative Nursing Record for Resident 7. 8. A review of the face sheet indicated Resident 8 was admitted with diagnoses including low back pain, and osteoporosis (fragile bones). A review of the MDS dated [DATE] indicated severe cognitive impairment. A review of the care plan for Resident 8 revised on 7/1/23, indicated, resident requires RNA program to maintain ADL function. During a review of the physician order for Resident 8 dated 7/31/23, indicated RNA Program: ambulation with FWW 3 X/week for 90 days to maintain functional mobility. A review of the Restorative Nursing Record for Resident 8 indicated RNA program was not implemented on 9/2023, 10/2023 and 12/2023. 9. A review of the face sheet indicated Resident 9 was admitted with diagnoses including muscle weakness and difficulty in walking. A review of the MDS dated [DATE] indicated severe cognitive impairment. A review of the care plan for Resident 9 revised on 7/28/23, indicated, the resident has an ADL self-care performance deficit r/t limited mobility. During a review of the physician order for Resident 9 dated 10/20/23, indicated, RNA Program for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056122 If continuation sheet Page 9 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056122 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Millbrae Care Center 33 Mateo Avenue Millbrae, CA 94030 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm AROM on BUE and BLE to maintain functional strength, maintain ROM and to decrease risk of contractures 3X a week for 90 days. A review of the Restorative Nursing Record for Resident 9 indicated RNA program was not implemented on 10/2023, 11/2023, and 12/2023. Residents Affected - Many 10. During a review of the face sheet indicated Resident 10 was admitted with diagnoses including stroke, history of left femur fracture, and history of falling. A review of MDS dated [DATE], indicated BIMS score of 6. A review of the care plan for Resident 10 revised on 8/12/23, indicated, the resident is at risk for falls and injuries r/t impaired physical mobility. During a review of the physician order for Resident 10 dated 10/20/23, indicated, RNA program AROM on BUE and BLE and ambulation with FWW to maintain functional strength, maintain ROM and decrease risk of contracture's every Tuesday, Thursday, and Saturday. A review of the Restorative Nursing Record for Resident 10 indicated RNA program was not implemented on 10/2023, 11/2023, and 12/2023. 11. A review of the face sheet indicated Resident 11 was admitted with diagnoses including history of falling. A review of MDS dated indicated BIMS score of 12. A review of the care plan for Resident 11 revised on 4/8/23, indicated, the resident requires RNA program for ambulation to maintain functional mobility. During a review of the physician order for Resident 11 dated 10/12/23, indicated, RNA Program for ambulation with FWW 3 X/week every Monday, Wednesday, and Friday. A review of the Restorative Nursing Record Resident 11 indicated RNA program was not implemented on 10/2023, 11/2023, and 12/2023. 12. A review of the face sheet indicated Resident 12 was admitted with diagnoses including stroke and hemiplegia. A review of MDS dated [DATE], indicated BIMS score of 13. During a review of the physician order for Resident 12 dated 10/6/23, indicated, RNA program AROM on BUE and BLE, and ambulation with FWW to maintain functional strength, maintain ROM, and decrease risk of contractures every Monday, Wednesday, Friday. A review of the care plan for Resident 12, revised on 12/4/23, indicated the resident has muscle weakness and difficulty walking. A review of the Restorative Nursing Record for Resident 12 indicated RNA program was not implemented on 10/2023, 11/2023, and 12/2023. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056122 If continuation sheet Page 10 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056122 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Millbrae Care Center 33 Mateo Avenue Millbrae, CA 94030 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 13. A review of the face sheet indicated Resident 13 was admitted with diagnoses including history of falling and muscle weakness. A review of MDS dated [DATE], indicated BIMS score of 12. A review of the care plan for Resident 13 revised on 9/8/23, indicated the resident has limited physical mobility. During a review of the physician order for Resident 13 dated 10/22/23, indicated, RNA Program for bed mobility and transfer, sit to stand, ambulation with FWW to maintain functional mobility, AROM on BUE and BLE to maintain functional strength, maintain ROM, and to decrease risk of contractures Monday, Wednesday, Friday. A review of the Restorative Nursing Record for Resident 13 indicated RNA program was not implemented on 10/2023, 11/2023, and 12/2023. 14. A review of the face sheet indicated Resident 14 was admitted with diagnoses including stroke and hemiplegia. A review of MDS dated [DATE], indicated BIMS score of 11. During a review of the physician order for Resident 14 dated 7/31/23, indicated, RNA Program for ambulation with FWW 3X/week Monday, Wednesday, and Friday. A review of the care plan for Resident 14 revised on 11/11/23, indicated the resident requires RNA ambulation to maintain functional mobility. A review of the Restorative Nursing Record indfor Resident 14 icated RNA program was not implemented on 10/2023, 11/2023, and 12/2023. 15. A review of the face sheet indicated Resident 15 was admitted with diagnoses including muscle weakness, difficulty walking and history of falling. A review of MDS dated [DATE], indicated BIMS score of 5. During a review of the physician order for Resident 15 dated 10/6/23, indicated, RNA Program for AROM on BUE/BLE to maintain functional strength, maintain ROM, and to decrease risk of contractures every Monday, Wednesday, and Friday. A review of the care plan for Resident 15 revised on 10/26/23, indicated the resident requires RNA program to maintain functional strength, maintain ROM, and to decrease risk of contractures. A review of the Restorative Nursing Record for Resident 15 indicated RNA program was not implemented on 10/2023, 11/2023, and 12/2023. 16. A review of the face sheet indicated Resident 16 was admitted with diagnoses including dementia and history of falling. A review of the MDS dated [DATE], indicated BIMS score of 13. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056122 If continuation sheet Page 11 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056122 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Millbrae Care Center 33 Mateo Avenue Millbrae, CA 94030 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many A review of the care plan for Resident 16 revised on 8/19/23, indicated the resident has an ADL self-care performance deficit r/t limited physical mobility. During a review of the physician order for Resident 16 dated 10/5/23, indicated, RNA Program for AROM to BUE and BLE to maintain functional strength, maintain ROM, and to decrease risk of contractures every Monday, Wednesday, and Friday. A review of the Restorative Nursing Record for Resident 16 indicated RNA program was not implemented on 10/2023, 11/2023, and 12/2023. 17. A review of the face sheet indicated Resident 17 was admitted with diagnoses including cerebrovascular disease (stroke) and hemiplegia (weakness of one side of the body). A review of MDS dated [DATE], BIMS score of 14. During a review of the physician order for Resident 17 dated 10/5/23, indicated, RNA Program for AROM on BUE and BLE to maintain functional strength, maintain ROM and to decrease risk of contractures every Monday, Wednesday, Friday. During an observation and interview on 1/11/24, at 11:23 AM, Resident 17 stated, I had a stroke. I paralyzed on my left side. I have contractures on my left arm. There is no RNA. I don't exercise. A review of the Restorative Nursing Record for Resident 17 indicated RNA program was not implemented on 10/2023, 11/2023, and 12/2023. 18. A review of the face sheet indicated Resident 18 was admitted with diagnoses including stroke. A review of the MDS dated [DATE], indicated little to no cognitive impairment. A review of the care plan for Resident 18 revised on 5/26/23, indicated, Resident has an ADL self-care performance deficit r/t impaired balance, limited mobility, and limited ROM. During a review of the physician order for Resident 18 dated 10/20/23, indicated, AROM on BUE and BLE, RNA for splinting on left elbow, left hand and left ankle to maintain functional strength, maintain ROM and to decrease risk of contractures every Monday, Wednesday, and Friday. During an interview on 1/11/24, at 11:30 AM, Resident 18 stated, We do not have an RNA, [RNA named] hasn't come back. I don't remember the last time I exercised. The splint? I don't think I ever worn them. It's there in cabinet in the next room. A review of the Restorative Nursing Record for Resident 18 indicated the RNA program was not implemented on 10/2023, 11/2023, and 12/2023. During an interview on 12/21/23, at, 10:36 AM, Administrator stated RNA 1 's last day of work was on 10/31/23, and RNA 2's last day of work was on 10/14/23. Administrator further stated, No one wanted to step up. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056122 If continuation sheet Page 12 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056122 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Millbrae Care Center 33 Mateo Avenue Millbrae, CA 94030 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete During an interview on 12/21/23, at 11:18 PM, MDS Assessment Nurse 1 stated that the residents were not referred to the rehabilitation department to reassessed for decline in functioning. The Director of Nursing was off work at this time. Review of the facility's Standards for Restorative Nursing Program dated September 2019, indicated, .Restorative Nursing Program is a service provided by the facility generally under nursing, to ensure maintenance of a patients optimum level of function. The residents (patients) on this program are encouraged or assisted to achieve and maintain their highest level of self-care and independence. These services must be performed daily . The Physical Therapist (PT) is responsible for providing the RNA with the necessary guidance to perform the restorative ambulation program .The RNA will be responsible for administering the restorative program on a daily basis and will assure that each patient is treated according to the therapist guidelines. The RNA will report any change in a patient's status to the therapist, Director of Nursing (DON) .in a timely manner .The nursing staff takes their order from the patients' (residents) physician (medical doctor) and is responsible to see that patient receives the necessary nursing care .The administrator is the person who sets the tone for kind of care provided within the facility. The administrator's knowledge and understanding of the restorative care can help both patient and family accept this type of programming as a vital part that it is of total patient care .A licensed nurse will reassess residents' outcomes and responses at least every 90 days and as necessary . Event ID: Facility ID: 056122 If continuation sheet Page 13 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056122 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Millbrae Care Center 33 Mateo Avenue Millbrae, CA 94030 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Actual harm Based on observation, interview, and record review, the facility failed to effectively assess weight loss, revise, and implement therapeutic interventions for one of one sampled resident (Resident 19) when Resident 19 had an unplanned weight loss. Residents Affected - Few The facility's failure resulted to Resident 19 to experience a gradual, unintended, progressive weight loss overtime. Findings: A review of the facility's Policy and Procedure (P&P) titled Weight and Assessment Interventions dated 11/2017, indicated, the threshold for significant and unplanned and undesired weight loss will be 5% after a month, 7.5% after 3 months, and 10% after 6 months. The P&P further indicated, .Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation .nursing will immediately notify the Registered Dietitian (RD). The RD will review the unit weight record every month to follow individual weight trends overtime. Negative trends will be evaluated by the interdisciplinary team. Individualized care plan shall address to the extent possible the identified causes of weight loss . Interventions for undesirable weight loss shall be based on careful consideration of the following: residents' choice and preferences; nutrition and hydration needs The policy did not address undesired weight loss in residents who do not meet the suggested thresholds. A review of the face sheet indicated, Resident 19 was admitted with diagnoses including dementia (a decline in memory or other thinking skills) and osteoarthritis (pain and stiffness of the joints). A review of the Minimum Data Set (MDS, a standard assessment tool) for Resident 19, dated 12/6/23, Brief Interview of Mental Status (BIMS, a brief memory test to help determine cognitive functioning [mental abilities, includes remembering, thinking,problem solving])score of 8 indicated moderate cognitive impairment. The MDS Section K (Swallowing/Nutritional Status) indicated, Resident 19 was not on physician-prescribed weight loss regimen. admission weight documented was 125 pounds (lbs). The admission diet order dated 7/31/21, indicated Resident 19 had a regular diet, regular texture, regular consistency. During an observation and interview on 12/19/23, at 1:13 PM, Resident 19 was alert, pleasant, verbally responsive in a foreign language. Resident 19 was sitting up at the edge of her bed feeding self with lunch. Certified Nurse Assistant (CNA, care giver) 3 stated, that Resident 19 usually eats a 100% of her meals. CNA 3 further stated, She's smaller now. She walks around a lot during the day and at night, and she takes a couple of rounds every time. CNA 3 also stated that Resident 19 will not ask for food but will accept and eat the food that was offered to her. During an observation on 12/20/23, at 2:36 PM, Resident 19 had walked the hallways in three rounds. During an interview on 12/20/23, at 3:12 PM, LVN(Licensed Vocational Nurse) 4 stated, (Resident 19 named) walks around all the time. You will always see her walking. LVN 4 as interpreter stated that Resident 19 likes to walk especially after meals, and that walking helps relieve her joint pains. During an interview on 12/20/23, at 4:35 PM, The Infection Preventionist (IP) stated, they were not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056122 If continuation sheet Page 14 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056122 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Millbrae Care Center 33 Mateo Avenue Millbrae, CA 94030 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 able to find the Initial Nutritional Assessment for Resident 19. Level of Harm - Actual harm A review of the RD notes dated 11/8/22 indicated, Resident 19's weight had trend down gradually. Residents Affected - Few A review of the RD (Registered Dietitian) notes dated 12/10/23, indicated, Resident 19 had a weight loss of 8 lbs. in 3 months and has a current weight of 98 lbs. During an interview and review of the nurses notes on 12/21/23, at 10:15 AM, the nurses' notes dated 12/11/23 indicated, Resident 19 had an 8 lbs. loss in 90 days and there were recommended supplements, Prostat (nourishment, protein supplement) 30 milliliter (ml, a unit of measurement) two times a day and Health shake (nourishment, nutritional supplement drink) daily. RN 1 stated, Weight loss is a change in condition and it should be monitored for 72 hours. The meal intake and nourishments should be charted. I don't see that the recommendation was followed up. During an interview and review of the nutrition plan of care (POC) on 12/21/23, at 11:02 AM, the POC initiated on 9/13/21, indicated Resident 19 was at risk for potential nutritional problem and malnutrition (caused by not having enough food to eat) related to Alzheimer dementia. Interventions included to monitor, evaluate and record of meal percentage intake, provide medpass, 120 ml with meals, multivitamin daily, report to Medical Doctor as needed (PRN) signs and symptoms (s/s) of malnutrition , serve diet as ordered, one ounce (oz) butter/olive oil added to entrees, RD to evaluate and make diet change recommendation as needed (PRN). Registered Nurse (RN) 2 reviewed the POC and acknowledged the POC further indicated on 11/8/22, Resident 19 weighed 103 lbs., a 14 lbs weight loss from 5/2022 weight of 117 lbs. And on 12/10/23, Resident 19 had a current weight of 98 lbs. a further weight loss of 8 lbs. from 9/2023 weight of 106 lbs. RN 2 stated, The care plan should be updated when she losses weight. There should be new interventions, example are supplements and what the dietician's recommended. The Director of Nursing and the MDS nurse reviews and updates the care plans. LVN 2 stated, I don't review care plans. LVN 3 stated, I don't review careplans. The POC did not address Resident 19's weight had trend down gradually as noted by the RD, and the interventions were last revised on 1/31/22. During an interview on 12/21/23, at 2:50 PM, RD stated, The supplement intake was documented by the nurses in the Medication Administration Record (MAR). Snacks, Sandwiches, juice, and cookies are available for the residents between meals and at bedtime. Regarding Resident 19's walking a lot during the day and at night as claimed by staff, RD stated that she needed to check on it. During an interview and review of the MAR on 12/21/23, at 3:02 PM, Licensed Vocational Nurse (LVN) 1 review the MAR and stated , The supplements were not given to Resident 19. During an interview on 12/21/23, at 3:20 PM, Social Services Designee stated, the social services have a backlog and the last care conference for Resident 19 was in 2022. During an interview on 12/21/23, at 3:48 PM, regarding Resident 19's weight loss, the Administrator stated that she need to check on it. During an interview and review of the Resident Daily Care Flow sheet (CNA flow sheet, Activity of Daily Living, ADL, documentation, includes eating, bathing) on 1/11/24, at 10:10 AM, the December (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056122 If continuation sheet Page 15 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056122 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Millbrae Care Center 33 Mateo Avenue Millbrae, CA 94030 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Level of Harm - Actual harm 2023 entries indicated that Snack/Supplement was both not offered nor accepted by Resident 19. CNA 3 stated, We were told that if there is a nourishment (Supplement/nutritional drink) on the meal tray, we have to chart it as snacks. It is confusing. LVN 2 reviewed the CNA flow sheet, and stated that the entries were confusing and cannot tell if the resident was given the snack and supplement. Residents Affected - Few During further an interview and review of the CNA flow sheet, on 1/11/24, at 10:14 AM, 11/2023 flow sheet indicated Snacks/nourishment was not offered, the 10/2023 flow sheet indicated Snacks/Supplement was not offered, and the 9/2023 flow sheet indicated Snacks/nourishment was not offered. Numerous omitted meal intake entries were found on the flow sheets for 9/2023,10/2023, 11/2023 and 12/2023. CNA 3 stated, that some of the registry staff (temporary replacement staff) were not completing the Activity of Daily Living (ADL, includes eating, bathing, bathroom use) documentation. CNA 3 further stated, They don't know the residents. They don't know the routine. They just leave after the shift. During an interview on 1/11/24, at 1:20 PM, the Director of Staff Development stated that he was not aware of the registry staff not completing the ADL documentation and has not address weight loss. A review of the physician's visit notes dated 12/13/23, did not address the weight loss of 8 lbs. in 3 months, from 9/2023 weight of 106 lbs down to 98 lbs. on 12/2023 for Resident 19. There was no assessment done to rule out any condition that might potentially cause the weight loss. The Director of Nursing was currently off work, and was not available for interview. Weight loss in nursing home residents is linked to poor outcomes, including higher rates of hospitalization and death (American Journal of Nursing 2008). A review of the Policy and Procedure titled, Comprehensive Plan of Care dated 12/16, indicated, .It is the policy of this facility to provide each resident with a comprehensive plan of care developed that includes goals, measurable objectives, and timetables to meet their medical, nursing, mental, and psychosocial needs identified during comprehensive assessment. The comprehensive care plan must describe the services that are provided to the resident to attain or maintains the resident's highest practicable physical, mental, and psychosocial wellbeing. The comprehensive plan of care will include, reflect interventions to meet both short- and long-term resident goals, interventions to prevent avoidable decline in function .include interventions to attempt to manage risk factors, be periodically reviewed and revised by interdisciplinary team as changes in the resident's needs .Reevaluate and modify care plans as necessary to reflect changes in care, services and treatment, quarterly and with significant change in status . A review of the Policy and Procedure titled Documentation Guidelines dated 11/21, indicated, .Guidelines .Promptly record as the events or observations occur . When a documentation error has been made in the record: dram a line through the error . Enter a new note or other documentation as specified . Do not leave blank spaces on forms . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056122 If continuation sheet Page 16 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056122 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Millbrae Care Center 33 Mateo Avenue Millbrae, CA 94030 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0825 Provide or get specialized rehabilitative services as required for a resident. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to provide Occupational therapy ( OT, used to improve abilities that are needed to live life as independently as possible) services to one of one sampled resident (Resident 20) when OT services was ordered by the physician. Residents Affected - Few The facility failure had the potential for further physical decline during Resident 20's stay in the facility. Findings: A review of the admission notes dated 8/31/22, indicated, Resident 20 had diagnoses including atrial fibrillation (abnormal heartbeat), diabetes (abnormally high sugar level in the blood) and diastolic heart failure (when the heart does not pump as strong as it should). The physician order dated 8/31/22, indicated Occupational therapy evaluation and treatment for Resident 20. A review of the OT evaluation notes dated 9/1/22, indicated, Resident 20 was referred to OT due to new onset of reduced Activity of Daily Living (ADL, includes eating, mobility, transfer, and walking) participation, reduce dynamic balance (ability to stay standing and stable while doing movements), decrease in functional mobility, decrease strength, fall risk, and increase need for assistance from others. The OT evaluation notes further indicated treatment plan including therapeutic exercises (activities designed to restore function, flexibility [ ability to move freely], and strength), and self-care management training, three (3) to five (5) times (X) a week for the duration of four (4) weeks, from 9/1/2022 to 9/30/2022. During a review and interview on 9/20/23, Rehabilitation Services Department (Rehab) Staff 1 reviewed the Occupational therapist (a healthcare provider) notes and acknowledged no treatments were provided to Resident 20 between 9/3/22 to 9/11/22. Rehab staff stated, I don't see any treatment notes here. The Occupational Therapist has terminated her employment. The rehab Director terminated employment in 11/2023. During an interview on 12/21/23, at 3:01 PM, the Infection preventionist stated, We cannot find a policy and procedure for rehab services. (Administrator named) said that the rehab department might have it. During an interview on 1/11/24, at 2:21 PM, the Rehab Director stated, the facility should have the policy and procedure for rehabilitation services. The facility was not able to provide the policy and procedure that addresses the rehabilitation services provided to the residents. The Director of Nursing was off work. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056122 If continuation sheet Page 17 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056122 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Millbrae Care Center 33 Mateo Avenue Millbrae, CA 94030 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on observation, interview, and record review the facility failed to implement its plan of action to correct the identified deficiency regarding the Restorative Nursing Assistant (RNA, nursing interventions that promote the resident's ability to perform activities of daily living as independently and safely as possible) Program. The facility failure resulted in non-compliance to F688 which had the potential for the residents to limit range of motion (ROM, how far a person can move or stretch a part of the body) and a possible development of contracture (shortening of muscles and joints which limits and interfere with daily functioning). (Refer to F688) Findings: During an interview on 1/11/24, at 1:58 PM, Administrator acknowledged there were no Restorative Nurse Assistants (RNA's) from 10/2023, and the facility's failure to implement their RNA Program, was not addressed during the QAPI meetings. The Administrator stated, Obviously we didn't. No one wanted to step up. The Director of Nursing was off work and was not available for interview. A review of the facility Policy and Procedure titled Quality Assurance and Performance Improvement Program dated 8/2017, indicated, It is the policy of the facility to establish and maintain an ongoing, systematic, and proactive facility wide process and data driven information to plan to measure and assess as well as to carry out the plan and improve resident care, outcomes, and safety . The facility QAPI program scope facilitates an interdisciplinary, interdepartmental collaborative approach for all areas of services provided by the facility that influences the outcomes in the provision of operations and clinical care to improve quality of resident life and care , resident choices, safety and appropriate utilization of resources through designation of performance improvement activities .The Governing Board and/or facility's administration with the help of the QAPI committee is responsible and accountable for ensuring that the QAPI program identifies and prioritizes problems and opportunities that reflect organizational process, functions and services provided to the residents based on performance indicator data, and resident and staff input, and other information . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056122 If continuation sheet Page 18 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056122 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Millbrae Care Center 33 Mateo Avenue Millbrae, CA 94030 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0911 Level of Harm - Minimal harm or potential for actual harm Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. Based on observation, interview, and record review, the facility failed to accommodate no more than four residents per room when one resident room contained a total of six residents. Residents Affected - Few This failure had the potential for residents to receive less privacy, care and attention, more noise and distraction. Findings: During an observation on 12/13/24 at 11 AM, one resident in the room was the last person at the end of the room with five other residents on either side of her. She did not speak English. Her room had visitors visiting two residents. The visitors were spread out around the two residents and standing outside of the residents privacy curtains. The room appeared dark, crowded, noisy, and less private for all of the residents. One resident angrily did not want visitors of other residents to be talking and visiting with others in the room and wanted the visitors to remain behind the privacy curtains of the resident they were visiting. Review of the number of residents in the room showed more residents in the room, (6), than the acceptable (4) residents per room. During an interview on 12/15/23 at 2:30 PM, the Administrator stated she would be applying for a room waiver to allow a six resident room. Review of Quality Assurance and Performance Improvement (QAPI) revised 8/03/23, indicated, Vision: The vision of facility is: To enhance and maintain the quality of care and quality of life of the ones we serve .Guiding Principle #8: The Outcome of our Quality Assurance Performance Improvement in our facility is to assist us to improve and enhance the quality of care and quality of life of our residents .Guiding Principle #9: Our facility takes any type of concern from a resident, staff or visitor as an opportunity for improvement. Guiding Principle #10 Our facility promotes and encourages participation, feedback and staff engagement in finding solutions to identify areas of concerns. Scope: The scope of the QAPI program encompasses all segments of care and services provided by facility that impact clinical care, quality of life, resident choice .The Quality Assurance Performance Improvement at facility will aim for safety and high quality with all clinical interventions while emphasizing autonomy and choice in the daily life for the residents' (or representative) .The facility will utilize the best evidence: . customer satisfaction to define and measure our goals. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056122 If continuation sheet Page 19 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056122 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Millbrae Care Center 33 Mateo Avenue Millbrae, CA 94030 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to respond to a residents call for staff assistance in a timely manner when Resident 38, one of 43 sampled residents, waited half an hour to receive peri-care (hygienic care) due to soiled undergarments. Residents Affected - Many This failure had the potential to cause skin injury and emotional distress to the resident. Findings: Resident 38 was admitted to facility 12/6/23 with diagnoses including diabetes, congestive heart failure, brain disease, open lower leg wound, and liver disease. The resident's Minimum Data Set, (MDS) an assessment tool, dated 12/13/23, indicated Resident 38 had a cognition score (thinking ability) of 10. (Highest score is 15). Resident 38 required an interpreter for language communication. Had impairment of both lower limbs, unable to walk, or reposition in bed or turn from side to side, and required toileting hygiene assistance. During an observation and interview on 12/19/23 at 4:40 PM, with wife present, resident stated he had to wait for a caregiver to provide peri-care over half an hour today. Resident 38 stated call light response time has always been slow and wait time is usually 30 minutes or more. Wife stated he has pain and needs medication, repositioning, or peri-care. During an interview on 12/21/23 on 2:30 PM, the Infection Preventionist did not have a reason for the residents wait time for peri-care. Review of the facility's Policy and Procedure on Answering Call Lights dated August, 2017, indicated, Purpose: The purpose of this procedure is to respond to the resident's requests and needs. Steps are taken to ensure that a resident's need and request is considered when request are made and when call lights are used to respond to needs at the time of use .6. Residents' call lights will be answered as soon as possible .9. Request should be fulfilled. If request cannot be fulfilled at the time of call light being answered, consider reporting and asking charge nurse or supervisor or a department manager for assistance . Based on observation, interview, and record review, the facility failed to ensure a functional communication system for 17 of 128 sampled residents (Residents 1, 4, 15, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, and 34) when call lights were broken in the resident bedrooms. The facility resulted in the residents not being able to call for help with their needs or in case of a fall injury while in their bedroom. Findings: 1. A review of the face sheet indicated Resident 1 was admitted with diagnoses including rheumatoid arthritis (painful swelling of the joints) and muscle weakness. A review of Minimum Data Set (MDS, a standard assessment tool) dated 10/6/23 Brief Interview of Mental Status (BIMS, a brief memory test to help determine cognitive functioning. Score 1-7 severe cognitive impairment, never/rarely make decisions. Score 8-12 moderate cognitive impairment, decisions (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056122 If continuation sheet Page 20 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056122 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Millbrae Care Center 33 Mateo Avenue Millbrae, CA 94030 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0919 poor, supervision required. Score 13-15 decision consistent/reasonable.) a score of 15. Level of Harm - Minimal harm or potential for actual harm During an observation and interview on 12/19/23, at 10:03 AM, in room [ROOM NUMBER] bed B, Resident was screaming, I'm wet. I need to be changed. Resident 1 stated she either had to yell out or make a phone call to the (receptionist named) to get help because her call light (a device placed in close proximity with a resident used as a communication device to relay care needs with the facility staff) hasn't work in six (6) months. Residents Affected - Many Resident 1 pressed the call light. The call light was observed not to light up or make any sound in the nurse's station where the panel was located. 2. A review of Minimum Data Set, dated [DATE], indicated Resident 21 has diagnoses including dementia (decline in memory or other thinking skills) and diabetes (abnormally high sugar level in the blood). BIMS score was 4. Resident 21 requires substantial/maximal assistance (helper does more than half the effort) with performance of Activity of Daily Living (ADL) including mobility, toileting, personal hygiene, and transfer. During an observation on 12/19/23, at 10:14 AM, in room [ROOM NUMBER] bed C, the call light for Resident 21 was pressed. The call light was observed not to light up or make a sound in the nurse's station where the panel is located. 3. A review of MDS dated [DATE], indicated Resident 22 has diagnoses including dementia and diabetes. BIMS indicated a score 11. Resident 22 requires set-up and clean up assistance during ADL. During an observation on 12/19/23, at 10:18 AM, in room [ROOM NUMBER] bed C, the call light for Resident 2 was pressed. The call light was observed not to light up or make a sound in the nurse's station where the panel is located. 4. A review of the most recent MDS dated [DATE], indicated Resident 23 has diagnoses including heart failure (when the heart does not work as strong as it should) and arthritis (pain and swelling of the bones). BIMS score of 15 indicated cognitively intact (decisions consistent/reasonable). During observation on 12/19/23, at 10:19 AM, in room [ROOM NUMBER] bed D, the call light for Resident 23 was pressed. The call light was observed not to light up or make a sound in the nurses' station where the panel is located. During an interview on 12/19/23, at 2:03 PM, the receptionist stated, I have received calls from [Resident 1 named] that she needs help from the Certified Nurse (CNA, caregiver) or a nurse. Then I paged to get their attention. She's not the only one that calls me. There's this other gentleman in room [ROOM NUMBER] A. 5. A review of the MDS dated [DATE], indicated Resident 5 has diagnoses including history of trans ischemic attack (TIA, mini stroke) and dementia. BIMS score was 4. During observation on 12/19/23, at 2:32 PM, in room [ROOM NUMBER] A, the call light was pressed. The call light was observed not to light up or make a sound in the nurse's station where the panel is located. 6. A review of the MDS dated [DATE], indicated Resident 29 has diagnoses including diabetes and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056122 If continuation sheet Page 21 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056122 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Millbrae Care Center 33 Mateo Avenue Millbrae, CA 94030 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0919 Level of Harm - Minimal harm or potential for actual harm asthma. BIMS score was 13. Resident 29 requires supervision or touching assistance with AD's including eating and toileting hygiene. During an observation on 12/19/23, at 2:34 PM, in room [ROOM NUMBER] B call light was pressed. The call light was observed not to light up or make a sound in the nurse's station where the panel is located. Residents Affected - Many 7. A review of the MDS dated [DATE] indicated Resident 30 has diagnoses including stroke and dysphagia (difficulty swallowing). BIMS score was 9. Resident 30 requires partial/moderate assistance (helper does less half the effort) with ADL's including eating and toileting hygiene, substantial/maximal assistance with bed mobility. During an observation on 12/19/23, at 2:37 PM, in room [ROOM NUMBER] C, Resident 30's call light was pressed. The call light did not light up or make a sound in the nurse's station where the panel is located. 8. A review of the MDS dated [DATE], indicated Resident 26 has diagnoses including stroke and hemiplegia (weakness of one side of the body) BIMS indicated severe cognitive impairment. During observation on 12/19/23, at 2:48 PM, in room [ROOM NUMBER] bed A, Resident 26 was screaming out for help. Resident in 26 was confused and unable to answer question. The call light for Resident 26 was pressed, no call light over the door or at the nurse's station illuminated. No noise from the call light system was heard. 9. A review of the face sheet indicated Resident 27 was admitted with diagnoses including seizures, diabetes (abnormally High blood sugar level). MDS dated [DATE] indicated BIMS core of 13. During an interview on 12/19/23, 3 PM, in room [ROOM NUMBER] bed B, Resident 27, stated, Yeah my call light is the only one that actually works. The guy next to me (bed C) doesn't even have a cord. But here's the [NAME], you can't turn mine off next to my bed, they have to turn it off over by the other guy's bed whose bell doesn't even work. It's all messed up man. They all know. They don't care. So, if I'm awake or around I'll call if I think they need something. Otherwise, we yell and eventually someone shows up. 10. A review of the MDS dated [DATE], indicated Resident 28 has diagnoses including epilepsy and dysphagia (difficulty in swallowing food or fluids). BIMS indicated severe cognitive impairment. Resident 28 requires substantial/maximal assistance with ADL's including mobility, transfer, personal hygiene, and toileting. During observation on 12/19/23, at 3:10 PM, in room [ROOM NUMBER] C, the call light was pressed. The call light was observed not to light up or make a sound in the nurse's station where the panel is located. 11. A review of the face sheet indicated Resident 31 has diagnoses including congestive heart failure and dysphagia. MDS dated [DATE] indicated BIMS score of 15. Resident 31 requires substantial/maximal assistance with personal and toileting hygiene, supervision/touching assistance with eating. During an observation on 12/19/23, at 3:35 PM, in room [ROOM NUMBER] A call light was pressed. The call light was observed not to light up or make a sound in the nurse's station where the panel is (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056122 If continuation sheet Page 22 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056122 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Millbrae Care Center 33 Mateo Avenue Millbrae, CA 94030 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0919 located. Level of Harm - Minimal harm or potential for actual harm 12. A review of the MDS dated [DATE], indicated Resident 32 has diagnoses including diabetes and difficulty walking. BIMS score was 12. Resident 32 requires supervision on performance of ADL's including transfer, toileting, and walking. Residents Affected - Many During an observation on 12/19/23, at 3:38 PM, in room [ROOM NUMBER] B call light was pressed. The call light was observed not to light up or make a sound in the nurse's station where the panel is located. 13. A review of the face sheet indicated Resident 33 was admitted with diagnoses including history of TIA and diabetes. Facility was not able to provide evidence of a current completed MDS for Resident 33. During an observation on 12/19/23, at 3:38 PM, in room [ROOM NUMBER] C call light was pressed. The call light was observed not to light up or make a sound in the nurse's station where the panel is located. 14. A review of the face sheet indicated Resident 34 has diagnoses including stroke and dysphagia. MDS dated [DATE] indicated severe cognitive impairment. Resident 34 required supervision with eating, maximal assistance with mobility and transfer, and was dependent with toileting. During an observation on 12/19/23, at 3:42 PM, in room [ROOM NUMBER] bed A, call light was pressed. The call light was observed not to light up or make a sound in the nurse's station where the panel is located. 15. A review of the most recent MDS dated [DATE] indicated Resident 24 has diagnoses including stroke. During an observation and interview on 12/19/23, at 3:44 PM, in room [ROOM NUMBER] bed A, the call light was pulled from wall with exposed wires, the cord was tangled. Resident 24 ([NAME]) stated, It's been like this and has not work for weeks. I have to yell when I need help or call the front desk. 16. A review of the MDS dated [DATE] indicated Resident 15 has diagnoses including dementia. BIMS indicated a score of 5. Resident 15 requires substantial/maximal assistance with ADL's including mobility, personal hygiene, and toileting. During observation on 12/19/23, at 4 PM, in room [ROOM NUMBER] bed C, Resident 15 had 2 call lights, one attached to each side of his bed. The Maintenance Supervisor untangled the cord closest to the 37 D bed and ran it across the floor next to the wall and gave it to the resident in the D bed, who was sitting up in a wheelchair. 17. A review of the MDS dated [DATE], indicated Resident 25 has diagnoses including dementia and heart failure. BIMS indicated a score of 6. During observation and interview on 12/19/23, at 4 PM, there was no call light found in room [ROOM NUMBER] bed D occupied by Resident 25. Maintenance Supervisor stated, Oh he does. We just need to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056122 If continuation sheet Page 23 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056122 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Millbrae Care Center 33 Mateo Avenue Millbrae, CA 94030 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0919 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many find it. See look it's here. The call light for Resident 25 was on the C bed. Resident 25 stated, I didn't know I had one. During an interview on 12/19/23, at 4:30 PM, Maintenance Supervisor acknowledged the nonfunctioning call lights in the resident bedrooms and stated, I am getting a new system. Getting quotes as we speak. It will be all working as soon as we get the parts. I've just been waiting on parts. We will get it done tomorrow. Maintenance supervisor provided the contact number and stated, You can call and ask if we get bid. A review of the facility Policy and Procedure titled, Answering Call Light dated 8/2017, indicated, .The purpose of this procedure is to respond to the resident's requests and needs. Steps are taken to ensure that a resident's [NAME] and request is considered when request are made and when call lights are used to respond to needs at the time of use . Ensure the call light is plugged all the time. When resident is in bed and confined to chair, the call will be placed within easy reach of the resident. Residents are encouraged to use call light. In case of some residents that is unable to use the call lights, residents will be check frequently. Reports all defective call lights promptly . A review of the Policy and Procedure titled Equipment Repair and Maintenance dated 12/2016, indicated, .The purpose of this policy is to ensure the proper functioning, safety, and reliability of all equipments used within the nursing home . The maintenance department is responsible for conducting routine inspections and preventive maintenance on all equipment. maintenance staff will keep detailed records of maintenance activities, including dates, findings, and actions taken,,,Any staff member who identifies malfunctioning equipment or observes a potential safety hazard must immediately report it to the maintenance department. A designated reporting mechanism, such as a maintenance request form or an electronic reporting system, will be in place. Regular inspections of all equipment will be conducted on a scheduled basis .Inspections will cover functionality, safety features, cleanliness, and overall condition .A preventive maintenance schedule will be establishes, outlining the frequency of inspections and maintenance activities for each type of equipment. The schedule will be reviewed and updated annually .The maintenance department will establish response time goals for addressing reported equipment issues based on severity. Urgent repairs posing an immediate safety risk will be addressed promptly .All repairs, whether routine or urgent, will be documented, including the issue identified, actions taken, and any replacement parts used. Detailed records of preventive maintenance activities will be maintained, including inspections reports, replacement parts, and any repairs conducted .Staff members will be trained on the reporting process for equipment issues and the importance of timely reporting . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056122 If continuation sheet Page 24 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056122 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Millbrae Care Center 33 Mateo Avenue Millbrae, CA 94030 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide a safe and sanitary environment when shower room [ROOM NUMBER]was found uncleaned and unhygienic. The facility failure has the potential for residents to cause uncomfortable experience during bathing and use of the shower room. Findings: During an observation in shower room one on 12/21/23, at 10:56 AM, on all four shower stalls, there were black gray substance on the grout in the walls, red substance splattered on the walls, brownish clay substance smeared all over the floor, and exposed rusty sharp pices of metal on all four shower stalls. The fabric curtains of the four shower stalls has holes sorrounded by black substance and brown substance smeared the lower bottom parts of the curtains. Six large containers were inside the shower rooom 1. During an interview on 12/21/24, at 11:23 AM, Certified Nurse Assistant (CNA, caregiver) 3 stated that the shower room [ROOM NUMBER] was currently used to give showers to all residents and that there was another shower room but has been closed for a couple of years. CNA 3 stated that it has been impossible to shower all residents with only one shower room, and said, We do what we can. CNA 3 stated, The red stuff was put about 3 months ago and the brown stuff on the floor was put last week. During an interview on 12/21/23, at 11:35 AM, Resident 42 stated, I'm supposed to have one shower twice aweek. I'm lucky if I get once a week. I'm supposed to get one today but it doesn't look like it is going to materialize. I stopped complaining here, it's a waste of time. These poor workers are trying but there isn't enough of them or what they need. It's terrible. During an interview on 12/21/23, at 11:45 AM, Maintenance Supervisor stated, Shower room [ROOM NUMBER] had been out of service for two weeks. It needs some plumbing work. Shower room [ROOM NUMBER] was locked and no available for inspection. MS stated, I dont have the key. I don't know who does. The Red Guard is the product that was the shower room [ROOM NUMBER]. The contractor is working on it. I want to change all that and use light blue and it will be done in the next year since we are so busy. Shower room [ROOM NUMBER] has molds in there and we are repairing the drains. MS provided a handwriten piece of paper that read, [NAME] (LA based contractor) and contact number and stated, You can call him. MS then left the room. During an interview on 12/21/23, at 12:02 PM, CNA 5 stated, We take the dirty linens and the garbage to the barrels in the shower room. The barrels are kept in the shower room until they get pick up. Im not sure when they get picked up. During an interview on 12/21/23, at 12:05 PM, MS further stated, I dont think the housekeepers can accommodate the cleaning schedule of the shower rooms. We do not have enough housekeepers staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056122 If continuation sheet Page 25 of 25